Investigations
Pregnancy status
Pregnancy status is one of the most important details to clarify when dealing with a patient presenting with vaginal bleeding and must be done as a matter of urgency.13,17 Point of care qualitative urine beta hCG tests are quick and easy to use. Occasionally, however, there may be a delay in obtaining a urine sample. For example, a woman who is hypotensive and shocked may be making little urine, or she may have just emptied her bladder prior to your assessment. Although most point of care tests are licensed for use with urine and/or serum only, these tests have been shown to be just as sensitive when used with whole blood.25–27 The result should be confirmed with a urine qualitative test +/- a serum quantitative test, but positives should be taken seriously.
Other Laboratory Investigations
Initial laboratory investigations for haemodynamically unstable patients are as follows:13,17
- Venous blood gas
- Full blood count
- Group and crossmatch
- Coagulation profile
- Renal profile
ED investigations for stable patients include:4,8,17,21
- Full blood count is indicated for patients with HMB or other significant bleeding.
- Coagulation profile should be sent if the patient is on anticoagulant or there is concern she may have a bleeding disorder.
- STI screen may be indicated if suspicion of infection.
- Testing for systemic causes of bleeding such as renal, liver or thyroid disease should only be undertaken in ED if there are symptoms to suggest an underlying disorder.
It should be noted that in most cases laboratory test results are non-specific and do not contribute to the ED management.21
Imaging
Pelvic ultrasound should be considered in cases of severe pain and bleeding to out rule serious structural causes such as haemorrhagic cysts, ovarian torsion, or a degenerating fibroid.21 In most cases, however, pelvic ultrasound can be arranged as an outpatient for stable patients as the results rarely change ED management.4,13,17,21
Learning bite
Beta hCG is the single most important investigation in patients presenting with vaginal bleeding. Most stable patients should have a full blood count checked but do not require further investigation in ED.